How the Cord Clamp Injures Your Babys Brain

March 20, 2002|20,592views

A major error in modern obstetrical
practice is routine premature clamping of the umbilical cord. Some sections
require medical knowledge for full comprehension and the language is very
technical, but overall, medical jargon is avoided or explained in terms
that most expectant parents can understand.

The
error was defined very clearly over 200 years ago:

"Another thing very injurious
to the child, is the tying and cutting of the navel string too soon; which
should always be left till the child has not only repeatedly breathed
but till all pulsation in the cord ceases. As otherwise the child is much
weaker than it ought to be, a portion of the blood being left in the placenta,
which ought to have been in the child."

Erasmus Darwin, (Charles
Darwin's grandfather) Zoonomia, 1801

Despite repeated publications
illustrating the effects of the error, and official notification, medical
academia and its peer review press have yet to acknowledge the possibility
of any error. Public exposure and knowledge of the issue is intended to
accelerate correction of the error.

The nature of the injury caused
by this practice unhappily precludes a cure; for the unfortunate parents
of an impaired child, the knowledge may assuage any guilt they may have
and give them reassurance regarding future births.

Modern obstetrics ignores the
normal functions of the cord and placenta from the moment that the child
is born, and in most hospitals the umbilical cord is clamped and cut at
the earliest convenient time after birth. [1][2]

At premature births and when
the newborn is depressed or "at risk," immediate cord clamping
is routinely performed in order to rush the child to a resuscitation table
and to obtain cord blood samples for medico-legal purposes. [3][4] Placental
blood, which ought to have been in the child, is either thrown away or
used to provide stem cells or other commercial products.

At this point, an explanation
of the terms anemia, polycythemia, hypovolemia and hypervolemia is required.
Blood is a mixture of red cells and plasma, a fluid. Blood is usually
about half cells and half plasma. When blood contains too few cells, the
term anemia is used; the blood is "dilute."

Polycythemia means there are
too many red cells - "concentrated" blood. The "-volemia"
terms refer to the total volume of blood in the child's heart and blood
vessels; blood vessels are elastic and are constantly filled by the heart
pumping blood through them, like a long, circular balloon.

Too much blood volume (hypervolemia)
overworks the heart and overfills the "balloon." Too little
blood volume (hypovolemia) lets the balloon and the heart collapse; it
makes no difference if the blood is diluted or concentrated.

Anemia and polycythemia are
about the quality of blood; hypo- and hyper-volemia are about quantity
of blood. An anemic baby may be hypervolemic - too much fluid, and a polycythemic
child may be hypovolemic - dehydrated. A normal child that suffers acute
blood loss will have a normal blood count and low blood volume (hypovolemia.)

During recovery from the hemorrhage,
blood volume is restored with fluid (plasma), and the child becomes anemic
(diluted blood) as it takes much longer to restore the lost red cells.
Early infant anemia is a strong indication that the child has suffered
significant previous blood loss.

Before
birth, the cord and placenta "breathe" for the baby.

Humans and all other mammals
have evolved, over millions of years, a very safe mechanism for closing
umbilical cords at birth without interrupting "breathing," and
ensuring optimal survival of their offspring.

An occasional natural accident
such as a ruptured cord may rarely occur, but it is biologically impossible
for that mechanism to routinely give a child too much, or too little,
blood; mammals that routinely give their offspring the wrong amount of
blood for survival become extinct in one generation.

Erasmus Darwin's late clamping
method is safe because the tie is placed on vessels that the child has
already closed physiologically (by natural constriction) after it has
received the right amount of blood; the tie does no harm because it virtually
does nothing.

Safe cord closure at birth
involves closing the placental life support system and starting the child's
life support systems without significant interruption of life support
during the changeover process. Oxygen supply and blood to carry the oxygen
are crucial to life support; blue blood contains little oxygen, red (pink)
blood is saturated with oxygen. Brain cells die quickly from lack of oxygen;
they do not regenerate, and asphyxiation (choking / lack of oxygen) for
about six minutes will cause permanent brain damage. [6]

Normal
Cord and Placental Function after Birth (No Cord Clamp Used)

Before birth, the lungs are
filled with fluid and very little blood flows through them; the child
receives oxygen from the mother through the placenta and cord. This placental
oxygen supply continues after the child is born until the lungs are working
and supplying oxygen - that is, when they are filled with air and all
the blood from the right side of the heart is flowing through them.

When the child is crying and
pink, the cord vessels clamp themselves. During this interval between
birth and natural clamping, blood is transfused from the placenta to establish
blood flow through the lungs. Thus the natural process protects the brain
by providing a continuous oxygen supply from two sources until the second
source is functioning well.

Placental blood transfusion
occurs by gravity or by contraction of the mother's uterus which forces
blood into the child. [7] Transfer of blood into the child through the
cord vein can occur after the arteries are closed (no cord pulsation).
The transfusion is controlled by the child's reflexes (cord vessel narrowing)
and is terminated by them when the child has received enough blood (cord
vessel closure).

The switch from placental to
pulmonary oxygenation also involves changing the fetal circulation to
the adult circulation - the one-sided heart (body blood flow only) changes
to a two-sided heart (blood flows through the lungs, then through the
body.) Ventilation of the lungs and placental transfusion effect this
change.

This is a very basic account
of a very complex process. [8] It all happens usually within a few minutes
of birth, and when the cord pulsations have ceased and the child is crying
and pink, the process is complete. Clamping the cord during the changeover
process disrupts these life support systems and may cause serious injury.

The
Effects and the Injuries of Immediate Cord Clamping (ICC)

The American College of Obstetricians
and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists
of Canada (SOGC) advocate immediate cord clamping at birth [3] [4] before
the child has breathed. This instantly cuts off the placental oxygen supply
and the child remains asphyxiated until the lungs function. Blood, which
normally would have been transfused to establish the child's lung circulation,
[9] remains clamped in the placenta, and the child diverts blood from
all other organs to fill the lung blood vessels. [1]

After immediate clamping, the
normal term baby usually has enough blood to establish lung function and
prevent obvious brain damage, but it is often pale, weak, and slow to
respond. Occasionally, a child will cry as soon as the head is delivered,
and the uterine contraction that delivers the child may also squeeze in
some placental transfusion before the fast clamp can be applied; however,
cord clamping before the first breath [9] always causes some degree of
asphyxia and loss of blood volume:

1. It totally cuts off the
infant brain's oxygen supply from the placenta before lungs begin to
function.

2. It stops placental transfusion
- the transfer of a large volume of blood (up to 50% increase in total
blood volume) that is used mainly to establish circulation through the
child's lungs to start them functioning.

Cerebral
Palsy Can Result From Premature Cord Clamping

While ICC is a danger to all
newborns, if a child is born asphyxiated and depressed following fetal
distress from cord compression (e.g. a tight cord around the neck) [10]
immediate cord clamping may very well be fatal. [9][1]

A child deprived of oxygenated
placental blood before birth is in dire need of oxygenated blood after
birth. Immediate clamping in such circumstances [11] often produces a
hypovolemic and asphyxiated child who cannot begin to breathe adequately
to relieve the asphyxia; oxygen in the lungs will never reach the brain
if the newborn does not have enough blood to flow from lungs to brain.
[12]

The medical term for the condition
that causes cerebral palsy (CP) is hypoxic, ischemic encephalopathy. (HIE)
Hypoxic means lack of oxygen - the child has no placental oxygen supply;
ischemic means lack of blood flow - half of the child's blood is in the
placenta; encephalopathy means brain damage.

HIE is often treated with blood
transfusion or blood volume expanders after a large part of the child's
own oxygenated blood has been discarded with the placenta. In addition,
babies with HIE usually develop anemia.

The obvious correct way to
resuscitate the depressed child is to keep the cord and placenta functioning
while ventilating the lungs. [1][9][12] If a child is born depressed with
a knot in the cord, should the knot be loosened or tightened? [11]

A newborn depressed from lack
of blood and lack of oxygen [10] is quickly restored to normal with a
large transfusion of oxygenated placental blood and is unlikely to develop
HIE. [12] Rapid restoration of oxygenation is crucial in preventing brain
damage in the depressed child, and that child must have enough blood to
transport oxygen to the brain.

If hypoxic brain damage has
occurred before birth, placental oxygenation and transfusion will not
cure it after birth - nothing will - but progression of the damage will
be prevented. Blood transfusion given after the child has developed HIE
will not restore the dead brain cells. Blood transfusions given in the
NICU are usually examples of "too little and much too late."

Fetal distress (intra-partum
asphyxia [13]) from cord compression, such as occurs with a cord prolapsed
during labor (a cord squeezed between the head and the cervix,) may be
rapidly reversed by relieving the compression - elevating the presenting
part (head) or changing the mother's position.

The fetal heart rate and monitor
tracing soon return to normal, and at delivery by emergency c-section,
the child may show no sign of asphyxiation. The same result can be obtained
at birth in a child asphyxiated with a tight cord around the neck by reducing
(unwinding) the cord and allowing the placental circulation to resuscitate
the child. [1]

The current standard obstetrical
practice is to clamp the cord immediately to obtain a cord pH [3][4] -
this maximizes the asphyxiation and hypovolemia, and accelerates HIE;
the life-saving blood in the placenta is thrown away while parts of the
child's brain die.

Learning
Disorders and Mental Deficiency

The varying degrees of cerebral
palsy and spastic paralysis are usually evident soon after birth in the
movement and reflexes of the child, but lesser degrees of hypoxic, ischemic
brain damage may remain hidden for years. [6] Iron deficiency anemia in
infants is associated with learning disorders and behavioral problems
to the point of mental retardation when these children reach grade school;
[14] the degree of mental retardation increases with more severe degrees
of infant anemia. [15]

At birth, no newborn is anemic;
adequate iron is supplied from the mother regardless of her iron status.
Any newborn that receives a full placental transfusion at birth has enough
iron to prevent anemia during the first year of life. [13] It is, therefore,
reasonable to conclude that full placental transfusion will prevent the
mental retardation, behavioral disorders and learning disabilities that
occur following infant anemia.

The immediately clamped newborn
may be missing one third to one half of its normal blood volume and is
very prone to develop infant anemia, [13] and as shown previously, it
is also at risk for hypoxic, ischemic brain damage at birth.

While some studies on treatment
of the anemia in infancy have shown some behavioral improvement, most
studies show no improvement or prevention of the brain dysfunction following
correction of anemia, [16] making it difficult to establish a cause and
effect relationship between anemia and brain dysfunction.

In HIE and CP (severe brain
dysfunction) anemia develops AFTER the brain is damaged. Moderate hypovolemia
and hypoxia at birth will produce infant anemia; it may also cause undiagnosed
minor brain damage [6] that will later produce behavioral defects.

Evidence
strongly points to infant anemia and behavioral brain dysfunction having
a common cause - immediate cord clamping; in other words, both anemia
and brain dysfunction are effects, not a cause and an effect.

In a comprehensive review of
cord clamping in 1982, Linderkamp concluded: "immediate clamping
can result in hypovolemia and anemia. ... A medium placental transfusion
appears to be more appropriate in order to avoid the risk of hyperviscosity,
whereas iron deficiency in later infancy is probably less dangerous."

And in a similar review in
1981, Peltonen stated: "Closing of the umbilical circulation before
aeration of the lungs has taken place is a highly unphysiological measure,
which should thus be avoided. Although the normal infant survives without
harm, under certain unfavorable conditions, the consequences may be fatal."
Within a few years, reports of these unharmed, "normal," anemic
infants being mentally retarded in grade school began to appear in the
literature.

While Linderkamp never proved
that "hyperviscosity," (a hematocrit of >65%) was any risk
at all to a newborn, Peltonen's remarks were based on his observations
of newborns' chests viewed under a fluoroscope, and he described incomplete
filling of the cardiac ventricles (decrease in heart size) following immediate
clamping; his use of the word "fatal" indicates that, after
immediate clamping, he witnessed a cardiac arrest that was not reversed.

His blunt advice to avoid the
procedure (he mentions no exceptions) emphasizes that the "normal"
child may not be free from risk. He did not advise repeating his experiment;
ACOG and SOGC [3] [4] do. Cardiac arrest, or inadequate cardiac output
for a few minutes, will produce permanent brain damage.

Immediate cord clamping is
clearly identified as a cause of newborn neurological (brain) injury ranging
from neonatal death through cerebral palsy to mental retardation and behavioral
disorders.

Immediate cord clamping has
become increasingly common in obstetrical practice over the past 20 years;
today, rates of behavioral disorders (e.g., ADD/ADHD) and developmental
disorders (e.g., autism, Asperger's, etc) continue to climb and are not
uncommon in grade school.

In the February 2000, I formally
requested that ACOG's ethics and practice committees revoke ACOG Educational
Bulletin 216 that was published in 1995. Reference #8 above points out
that ACOG has been unable to provide an informed consent for immediate
cord clamping.

In the February 2002 edition
of Obstetrics & Gynecology, ACOG quietly announced, in very small
print on a back page (361), that Bulletin 216 has been withdrawn from
circulation. I have yet to receive a formal reply from ACOG.

For the past seven years, thousands
of obstetricians have been taught that immediate cord clamping is an acceptable,
standard obstetrical procedure, and millions of newborns have been subjected
to it.

Without any attempt at warning
the profession, ACOG has quietly relieved its officials from further responsibility
for an injurious procedure that is widely and naively performed by many
practicing obstetricians. It would be ethically and morally appropriate
for ACOG

To
Announce To Every Obstetrician In Very Large Print:

1. That immediate cord clamping
is no longer officially sanctioned as standard care.

2. That the person who clamps
the cord before the lungs are oxygenating the child should have sound,
documented, clinical justification for doing so and

3. That the person who clamps
the cord immediately or prematurely is individually responsible and
liable for the resulting injuries.

George Malcolm Morley, MB,
Ch.B., FACOG

Dr. Morley graduated from Edinburgh
University Medical School in 1957, completed a residency in OBGYN in 1962,
and practiced obstetrics and gynecology until his retirement in 1999.
He is board certified in OBGYN, and a Fellow of the American College of
Obstetrics and Gynecology.

Criticism, comment and refutation
on this article is encouraged and may be sent to:

Life is difficult enough
without having to struggle with giving newborns additional challenges
to contend with. It would seem more than prudent to select a "naturally
oriented" maternity care provider who will not use a cord clamp too
soon and will avoid many of the other detrimental practices of modern
obstetrical care.

The mission of Cordclamping.com
is to educate physicians, midwives and patients about normal placental
function during the third stage of labor and the injuries caused by
interrupting it, as well as to ensure the structural and functional
integrity of every newborn's brain by the correct use of the cord clamp.

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